Pain Flares-ups: A Brief Look at the Evidence

There is now a vast amount of information and evidence showing the global burden created by musculoskeletal pain. (just to name a few – here, here, here,here – there are way more than this!) The widespread negative impact created by pain on an individual’s function is mind-boggling. As I recently sorted through some evidence about pain flare-ups I arrived at the question:

“To what extent do poorly treated pain flare-ups add to the burden of persistent pain?”

A Brief Look at the Evidence

-Prolonged sitting (>6 hours) in the past 24 hours was the only activity significantly associated with a flare-up. There was a four-fold increase in flare up risk compared to not sitting for prolonged periods.

-Other activity involving physical exertion did not trigger flare-ups during the course of acute LBP.

-Having either stress or depression in the past 24 hours was significantly associated with twice the risk of a LBP flare-up.

-PT was found to be a deterrent of flare-ups.

-The study focused only on flare-ups of a current acute pain episode. Discussion distinguished how triggers for a flare-up of existing LBP may differ from triggers of a new onset of LBP.

Article 2: The 2017 article by Stechell et.al.(2) “What Constitutes a back pain flare” discussed previous research on flare-ups and their significant impact. The studies discussed showed 96% of people with LBP reported at least 1 flare-up in the past 12 months. While 36% reported at least 10 flare ups. Furthermore 36% could not work, 21% bed-ridden, and 19% were dependent on others for self-cares during the flare.

The primary focus of Stechell’s group was on patient perception of a pain flare. Patients with ongoing pain were asked to describe what a flare-up meant to them. The answers were more complex than just a pain increase. Many times it is assumed that a flare-up means just an increase in pain. Though patient perception of a flare was multi-dimensional to include unpleasant sensations, loss of function, being difficult to alleviate, and changes in emotions and cognitions lasting hours to weeks.

Article 3: Finally, a 2018 systematic review (3) examined how symptom flare is defined in twelve musculoskeletal conditions. Here are some of the findings:

-Many with LBP consider their condition to be ongoing, variable, and characterized by “flares”; rather than discrete episodes of pain (even if they have pain-free periods).

-The ability to define what a flare-up is and arrive at a universal consensus has been challenging to achieve in many musculoskeletal conditions.

-There are big differences in how health care providers interpret the symptoms of a flare-up compared to a patient’s perspective of a flare-up.

-There are different risk factors that contribute to flare-ups versus a new first-time episode of pain.

-A flare-up cannot be distilled to a simple consideration and is instead a multifaceted individual experience.

My Thoughts:

Pain flares can be experienced across the spectrum of pain states. It does not matter if the pain experienced is acute, chronic, or anywhere in between. Reports that pain, or symptoms, have flared is a common occurrence in the clinic. How often do you hear, “I was doing great, until yesterday… now I am flared-up again”?

The impact of pain flare-ups is often underappreciated as they create challenges for individuals trying to fully recover from a pain episode. It could be argued a primary reason acute pain becomes persistent is the unabated cascade of symptom flare, fluctuation, and progression over time leading to maladaptive beliefs and behaviors about the condition. A lack of knowledge, or unsuccessful coping strategies, make it easy for some to conclude hurt equals harm. Perhaps the most natural response to pain is to protect (by limiting and restricting activity) until the pain eases. Though too often the cycle of self-limiting and activity restriction leads to ongoing pain and greater functional limitation.

I am convinced that doing a better job of treating flare-ups is necessary and vital to help shift the burden of musculoskeletal conditions. My current clinical experiences, grounded in pain neuroscience education and a biopsychosocial approach, suggests that the best method for treating flare-ups is helping an individual develop successful coping skills. Coping skills are like any other learned skill. They take time, practice, and understanding to master. In a future blog I hope to highlight some essentials of developing effective coping strategies.

What do you think? How important are coping strategies to successfully treat pain and symptom flare-ups?

6 responses to “Pain Flares-ups: A Brief Look at the Evidence”

Thanks for sharing such a nice summary of these articles and your thoughts. I think you are spot on re: coping skills. Intertwined with that is normalizing the experience by teaching patients that flare-ups are common, but there are many things we can do to nip the in the bud when they do occur. “No freaking out over flare ups.” Looking forward to your next blog on this great topic!

Thanks Jessie,
I am learning that superior coping skills are essential for success. In general, they seem to be under utilized on a day to day basis. There is so much to accomplish in short 1:1 patient care times, I often see developing coping strategies rank low on the intervention to-do list. While most everyone recognizes their value, they are left to addressing only when they are needed (flare-ups or setbacks). Preparing ahead, in little bits, goes a long way…

Great article. During my initial exam and treatment, I try to paint a picture of what to expect. Such as perhaps, you may experience soreness from initial treatment. Also state that in treatment there can be good days, and days that pain will occur again. I use the analogy, that even when we aren’t hurting or in pain, some days we just feel pain. I find this will help, if and when the patient does have the flair ups. They aren’t caught off guard.

Thanks for your comments Phil. Great thoughts, I think you nailed it! Helping create early expectations is a key part of getting out in front of a the inevitable flare up. When patient expectations are on the same level as the reality of their condition the better things seem to go. I find the greater the distance between patient expectations and realistic expectations, the more room there is for frustration and other emotions to creep in. This can be limited by doing exactly what you do; painting a realistic picture of expectations as you describe.

Very interesting and clinically applicable. The stand out point for me is the first article citing sustained sitting as the only activity associated with flare up, and the association with stress and or depression. I find both to be clinically consistent and significant, it seems especially in females. Stress often seems to choose to reside in the pain perception/pathway, This association seems to be more rather than less common in current society.

Sean,
I also thought it was interesting to see the 3 variables for flare-ups in acute lbp. It is often assumed that physical activity causes flare-ups. I have shared this info with a couple of patients recently and it was fun to see a light bulb go off. Both said something like, “funny you say that, I sat all day 2 days ago, then my pain was back”. This all points back to the power of knowledge as a corner stone of being able to cope well with pain. Thanks for reading.